- Email: [email protected]
Extended Hours Working in Radiotherapy in the UK
Clinical Oncology (2007) 19: 213e222 doi:10.1016/j.clon.2007.01.442
Original Article
Extended Hours Working in Radiotherapy in the UK L. White, E. Beckingham, F. Calman, C. Deehan Guy’s and St Thomas’ NHS Foundation Trust, St Thomas’ Hospital, Lambeth Palace Road, London SE1 7EH, UK
ABSTRACT: Aims: To analyse extended hours working patterns within UK cancer centres and to assess alternatives to the normal 9.00 am to 5.00 pm working day. Materials and methods: Questionnaires were sent to 62 radiotherapy managers in June and July 2005 to survey where extended hours working had been implemented, the objectives for using a longer working day and how departments organised their service issues, including staffing levels, costs and patients. This was followed by visits to six departments that were working extended hours. A second questionnaire sent to 60 radiotherapy physics managers in September 2005 requested information for the hours of daily, monthly and annual megavoltage machine servicing and quality assurance (QA). A third questionnaire was distributed to all radiotherapy outpatients from four departments who attended on a single day of survey in 2005. It looked at patient preference for treatment hours. Results: In total, 57 (92%) radiotherapy managers responded. Thirty-one departments (55%) were working extended hours, 22 (39%) had short-term experience and three (5%) departments had no experience. Increasing capacity to reduce waiting lists was the main reason for working extended hours. The additional hours were predominantly worked by radiographers, with little or no support from the other department disciplines. The servicing and QA spreadsheet was returned by 53% (n [ 32) of physicists. The average amount of servicing and Quality Assurance (QA) work being scheduled out of hours in each department was 35% (0e100%). The patient questionnaire was completed by 470 patients. When asked if patients would want to come to a reasonable appointment time outside of the normal working day, 29% (n [ 136) said ‘yes’ and 12% (n [ 55) were unsure. Conclusion: It was concluded that two shifts covering an 11.5 h working day is a robust alternative to the normal working day, taking into consideration efficient use of radiographers and patient preference for out of hours appointments. White, L. et al. (2007). Clinical Oncology 19, 213e222 ª 2007 Published by Elsevier Ltd on behalf of The Royal College of Radiologists. Key words: Capacity and demand, patient choice, radiotherapy, servicing and QA, work patterns
Introduction The NHS cancer plan [1] provided the framework for raising standards in treatment and care and for providing faster more effective cancer services. In December 2005, the plan set the target interval times for all cancers at a maximum of 1 month from the date of the decision to treat to the first definitive treatment and 2 months from an urgent general practitioner referral to the first definitive treatment. The adverse effects of delay in the radical treatment of cancers, particularly for category I patients, have been reported [2,3]. Therefore, the target times are recognised as good practice, and reflect those originally specified by the Joint Council for Clinical Oncology in 1993 [4]. However, the targets come at a time when the maximum recommended waiting interval for radical treatment is being exceeded by 53% of cancer patients in the UK [5]. Increased capacity and a streamlining of services are required to ensure that the targets are met. In England, the NHS cancer plan pledged significant capital investment to replace 42 old machines and to initially install an additional 0936-6555/07/190213þ10 $35.00/0
14 new linear accelerators with a further 45 additional linear accelerators to be delivered over the following 3 years. By 2004, the National Health Service had received 83 linear accelerators, achieving the target of 4.0 linear accelerators per million [6]. In 2003, the Royal College of Radiologists (RCR) published a report providing recommendations on radiotherapy equipment levels and staffing for service planning [7]. The report advised that the target of the NHS cancer plan was no longer relevant and recommended sufficient linear accelerators to achieve a provision equivalent to 5.5e6.0 per million population if departments were to achieve the optimum outcome from modern radiotherapy and have the capacity to reduce waiting times. This was supported by the ESTRO QUARTS project, which calculated an evidence-based best estimate of 6.5 linear accelerators per million population for the UK [8]. The RCR report also warned that the 2003e2006 Government investment programme for linear accelerators in England would only address the problem of out-of-date radiotherapy machines and not increase capacity.
ª 2007 Published by Elsevier Ltd on behalf of The Royal College of Radiologists.
214
CLINICAL ONCOLOGY
Inadequate equipment provision is not the only factor affecting capacity. The problem is compounded nationally by the shortage of qualified radiographers, physicists and technical staff of all grades [7,9] and locally through the inevitable loss of capacity that can result from machine breakdowns, public holidays and staff sickness. As a result, radiotherapy departments have had to look at ways to make further use of the assets already available. For many years, radiotherapy facilities, like most outpatient departments, have based appointment hours around a nominal 9.00 am to 5.00 pm, 5 day working week. One option for an immediate increase in capacity is to extend the working hours. Most departments already have experience of short-term extended hours working to compensate for reduced capacity during machine breakdown or increased demands on the service. More recently, a number of departments have implemented long-term, sustained extended hours working to tackle waiting lists. The use of extended hours is seen as a natural complement to the patient’s choice agenda, which has recently gained momentum [10]. ‘Public patient involvement’ is now an integral part of service development. A key objective of the Cancer Services Collaborative ‘Improvement Partnership’ is to predict patient requirements in advance and pre-plan and pre-schedule care at times to suit them [11]. Extended hours working would therefore seem not only to provide an increase in capacity, but also to have the additional outcome of offering patients a greater range of appointment slots beyond the normal working week. The successful adoption of extended hours working has implications for all aspects of a radiotherapy department. The potential advantages, disadvantages and costs of working an extended day have already been considered in detail in an RCR publication in 1997 [12]. For the current project, data were collected through two questionnaires (to radiotherapy and radiotherapy physics departments) to highlight the use of extended hours working in the UK and to describe how the radiotherapy service was being delivered during the extended hours (Fig. 1). A third questionnaire considered patient preference for radiotherapy appointment times. For departments considering moving to extended hours working or increasing their extended hours, this paper also compares models of extended hours working arrangements for the delivery of radiotherapy services within the National Health Service. For the purpose of this paper, ‘extended hours working’ is defined as hours that are worked to provide regular treatment appointments either before 9.00 am and/or 5.4% Currently working extended hours Short-term experience of working extended hours
39.3% 55.4%
Never used extended hours working
Fig. 1 e Extended hours working in radiotherapy departments in the UK.
after 5.00 pm, Monday to Friday, thus giving a working weekday that is longer than 8 h. This is adjusted for departments that have historically worked from 8.00 am to 4.00 pm. A 36 h week was used as the 37.5 h week under Agenda for Change had not yet been widely implemented in radiotherapy at the time of the survey. Extended hours working includes all hours worked at weekends except those worked to provide Continuous Hyper-fractionated Accelerated RadioTherapy (CHART) or as part of an out of hours on-call arrangement.
Materials and Methods Three independent questionnaires were distributed as part of the data collection to give a global view of radiotherapy practice at that time.
Radiotherapy Questionnaire The first questionnaire was developed with the aim of collecting data on the national use of extended hours working. The questionnaire was mailed in two cohorts in June and July 2005 to the managers of 62 radiotherapy departments in the UK. The 20 departments in the first cohort were selected from the equipment and workforce survey carried out by the National Cancer Service Analysis Team in July 2002 [13]. All of the departments had reported working an extended day in the NatCanSAT survey. The second cohort was sent in July 2005 to the remaining departments. There were no exclusion criteria. The questionnaire was self-administered and applied a filter. Respondents were given 3 weeks to complete the questionnaire. A follow-up telephone call was made at the end of the second week to the 18 managers in cohort 1 and the 24 managers in cohort 2 who had not already replied. Departmental visits The returned questionnaires were used to select six departments from across the UK for local visits. The selected departments were all working extended hours at the time of the visits and were of varying sizes, locations (city centre and out of town) and with different models of extended hours working in operation. The visits were attended by three members of the project team comprising a superintendent radiographer, a senior radiotherapy physicist and the project manager. Unstructured interviews were held with all the staff groups involved in delivering the radiotherapy service and were used to further explore the issues and logistics of maintaining sustained extended hours working.
Radiotherapy Physics Questionnaire The second questionnaire was distributed to departmental heads of radiotherapy physics in September 2005. Information was requested in a spreadsheet format for the hours of daily, monthly and annual megavoltage machine servicing and quality assurance (QA). The data
EXTENDED HOURS WORKING IN RADIOTHERAPY IN THE UK
were divided into work scheduled during the normal working week, during an extended day and at the weekend. The spreadsheet allowed for machines in the same department that follow different maintenance schedules. The questionnaire was distributed by e-mail to 60 heads of radiotherapy physics (two physicists managed services across two centres) with a 1 week deadline.
Patient Questionnaire The third questionnaire was distributed to radiotherapy outpatients from four inner city departments regularly working extended hours. All questions were multiple choice. Every radiotherapy outpatient who attended each of the four centres on the day of survey in December 2005 was asked to complete the questionnaire. The survey was only issued on a single, full day to prevent duplication through patients attending for treatment on consecutive days. Patients were provided with a questionnaire by a member of their radiotherapy team while they waited for treatment. The questionnaire was self-administered. Care was taken to assure patients that participation was voluntary and that all responses were anonymous and would not be used to decide the patient’s own future appointments. Data collected from all three questionnaires were summarised collectively using percentages, means, ranges and standard deviations. Further analysis of the patient data will be provided in a separate communication.
Results Radiotherapy Managers’ Questionnaire The response rate for cohort 1 was 90% (n ¼ 18) and 92.9% (n ¼ 39) for cohort 2. The overall response rate was 91.9%. One returned paper was excluded from the analysis due to inadequate completion. Responses showed that 50% (n ¼ 28) of radiotherapy departments were routinely working extended hours. Three radiotherapy managers did not consider their departments to be operating an extended day when their current machine hours showed otherwise (by the project’s definition of extended hours working). Thus, the actual number of departments that were working extended hours increased to 55.4% (n ¼ 31). However, these departments could not be included in the subsequent analysis due to the filter. Of those departments not routinely working extended hours, 88% (n ¼ 22) had temporarily used the service arrangement. Only 5.4% (n ¼ 3) of all responding radiotherapy departments had never used extended hours working. Departments currently using extended hours working Table 1 shows the two main reasons why radiotherapy departments were using extended hours working. Other reasons included: to accommodate servicing and QA during the normal working day (n ¼ 2), to facilitate radiographer run-ups (n ¼ 1), to accommodate more complex treatments
215
Table 1 e Reasons for the use of extended hours working Reason Increase capacity Equipment replacement Other
No. (%) 23 (82.1) 4 (14.3) 6 (21.4)
(n ¼ 1), to improve recruitment and retention through uplift of radiographer salaries (n ¼ 1) and local Trust-wide terms and conditions regarding staff hours (n ¼ 1). Five departments provided more than one reason. A working paper or formal business case was not produced before implementation by 42.9% (n ¼ 12) of the radiotherapy departments. Extended hours working had been operating for a year or less in 14.3% (n ¼ 4) of departments and between 1 and 5 years in 28.6% (n ¼ 8). Eleven departments (39.3%) had used extended hours for more than 5 years. Table 2 shows how departments were managing the staff costs from operating extended hours working. For the most part, the extended hours were being accommodated through flexible working and time off in lieu with no additional staff costs. The longest working day covered by radiographers was 8.15 am to 9.00 pm. For radiotherapy physics and engineering it was 6.30 am to 9.00 pm. Radiographers were working shifts in 53.6% (n ¼ 15) of radiotherapy departments and 17.9% (n ¼ 5) needed to schedule three shifts in a working day to cover either a 10 h day (n ¼ 4) or a 12 h day (n ¼ 1). A 4 day week (n ¼ 4) or a 9 day fortnight (n ¼ 1) was used by 17.9% of departments. Shift working was used in 25% (n ¼ 7) of radiotherapy physics departments, of which five departments scheduled three shifts in a working day. In departments where both radiographers and radiotherapy physics were working shifts (n ¼ 5), the working day of the radiotherapy physics department was longer by a mean of 1.4 h (range 0e2.5 h) than that of the radiographers. The mean number of additional hours worked each week per department was 15.3 h (range 3e50 h) on a mean of 2.7 machines (range 1e8). In all, 68.6% of the 116 megavoltage machines that were in regular use were being used by departments that operate extended hours working. Across the course of a working week (Monday to Friday), a mean total of 7.0 h (range 0e20 h) was worked before the Table 2 e Department funding of extended hours working Funding Flexible working/shifts Overtime Increased establishment Increased budget 37.5 h week as standard Not stated
No. (%) 20 4 3 1 2 1
(71.4) (14.3) (10.7) (3.6) (7.1) (3.6)
Three departments reported more than one funding mechanism.
216
CLINICAL ONCOLOGY
by 67.9% (n ¼ 19) of departments. A breakdown of the criteria used by these departments is shown in Table 6. Transport was the primary factor, with 84.2% (n ¼ 16) selecting patients who had their own transport. Patients with breast or prostate cancer were generally considered first, whereas patients with complex treatment plans were usually excluded. Patients in a general good state of health and not requiring any additional support were also being selected.
start of the normal working day and a mean of 8.3 h (range 0e35 h) was worked at the end of the normal working day. More than an additional 10 h a week was being worked in 50.0% (n ¼ 14) of radiotherapy departments and 32.1% (n ¼ 9) were operating in excess of an additional 20 h a week. One department reported regularly working at the weekend for routine treatments, running a single machine for 4 h on Saturday morning. Only four departments (14.3%) stopped machines for lunch or breaks and this was due to staff shortages in all instances. Table 3 shows the radiographer staffing for extended hours working. The table does not include departments that were using a 4 day week working pattern, as staffing is constant throughout the day (excluding part-time staff). Typically, each machine was being run by three radiographers with support cover from a clinical superintendent acting as supervisor across all the participating machines. The mean level of support from radiographer helpers and assistant practitioners was low. Table 4 shows the department staffing for all other professions. In nearly all cases, patients who required planning, simulation or the mould room were seen during normal working hours. Although medical support in the department was low, all had on-call support. Access to peripheral services was also low, with 82.1% (n ¼ 23) having access to neither radiology nor pharmacy during extended hours. Hostel accommodation for patients was not offered by 67.9% (n ¼ 19) of departments. Hospital transport also proved difficult, with 82.1% (n ¼ 23) not being able to offer hospital transport before the beginning of the normal working day and 96.4% (n ¼ 27) unable to offer transport after the end of the normal working day. Table 5 shows the terms and conditions of radiographers and radiotherapy physics staff who worked extended hours. It can be seen that despite there rarely being a financial incentive to participate in extended working hours, staff in both groups were expected to participate. Eight radiotherapy departments (28.6%) formally consulted their patients as part of the decision to introduce extended hours working. Of these centres, all found patients were willing to come as early as 8.00 am. The latest patients were willing to attend ranged from 4.30 pm to 8.30 pm. However, 8.00 pm was the most common (n ¼ 3). Preferred selection criteria to book specific patients to the appointment slots during the extended hours were used
Departments that have short-term experience of extended hours working It was found that 39.3% (n ¼ 22) of responding departments had short-term experience of extended hours working, but were using normal working hours when the questionnaire was distributed. The most common objective for short-term use of extended hours was to reduce waiting lists. This applied to 50% (n ¼ 11) of departments. Extended hours during machine maintenance was cited by 36.4% (n ¼ 8) and during linear accelerator replacement by 27.3% (n ¼ 6). Four departments gave more than one objective and one department did not state an objective. Most departments that used extended hours working in the short term incurred additional radiographer costs. Overtime payments were paid by 68.2% (n ¼ 15) of responding departments. Only three departments received supplementary short-term funding through local initiative schemes to support the additional costs. The mean number of megavoltage units used for the short-term use of extended hours working was 1.7 (range 1e5). The mean number of additional hours was 3.1 (range 0.5e4.25 h) per day. The staffing allocation can be seen in Tables 3 and 4. No departments included planning, simulator or mould room services as part of the short-term use. Two departments (9%) had medical support during the extended hours and five (22.7%) had nursing support. None of the departments had administrative and clerical support. Only three departments (13.6%) failed to achieve their objectives for the introduction of short-term use of extended hours. Two departments reported finding it difficult to sustain the extended hours working with the number of staff in the department. The third department found that the throughput of patients was limited by simulator capacity. Thirty-two per cent (n ¼ 7) of the
Table 3 e Radiographer staffing per machine during extended working hours (mean [standard deviation])
Staff grade Senior radiographers Radiographers Assistant practitioners Radiographer helpers
All departments regularly working extended hours (n ¼ 28) 1.58 1.37 0.17 0.25
(0.7) (0.7) (0.4) (0.4)
Departments regularly working more than 10 additional hours per week (n ¼ 14) 1.65 1.70 0.14 0.20
(0.7) (0.7) (0.5) (0.4)
Departments regularly working more than 20 additional hours per week (n ¼ 9) 1.58 1.67 0.21 0.17
(0.8) (0.8) (0.6) (0.4)
Staffing during short-term use of extended hours 1.81 1.35 0.05 0.27
(0.9) (0.7) (0.2) (0.5)
EXTENDED HOURS WORKING IN RADIOTHERAPY IN THE UK
217
Table 4 e Non-radiographer staffing during extended working hours (mean [standard deviation])
Profession Physicists Technicians Planning Simulator Mould room Medical Nursing Administration and clerical
All departments regularly working extended hours (n ¼ 28) 0.57 0.63 0.15 0.34 0.10 0.36 0.22 0.29
Departments regularly working more than 10 additional hours per week (n ¼ 14)
(0.8) (0.6) (0.4) (0.7) (0.3) (0.6) (0.5) (0.5)
0.64 0.50 0.08 0.55 0.10 0.00 0.20 0.17
departments who had used extended hours successfully noted they would be unable to use extended hours again due to the lack of staff and additional funding to support it. Three departments (13.6%) reported that extended hours working would probably be reintroduced in the next 12 months to meet the cancer targets.
Departments that have never implemented extended hours working Three responding departments (5.4%) had never used extended working hours. All three departments reported Table 5 e Terms and conditions and access to workplace for 28 departments working extended hours Radiographers
Physics
Yes (%) Terms and conditions Were staff consulted? Is it in their contract of employment? Is it voluntary? Is it expected that they will participate? Is there a financial incentive? Access to workplace Do most staff live locally? Do most staff use public transport? Do most staff use their own transport? Is there designated parking available? Are there cre `che facilities available?
93.8 70.6
88.9 57.9
55.9 82.9
61.8 88.2
25.7
29.4
48.6
50.0
21.6
18.9
83.8
89.2
48.6
60.0
48.6
33.3
(0.7) (0.5) (0.3) (0.8) (0.3) (0) (0.4) (0.4)
Departments regularly working more than 20 additional hours per week (n ¼ 9) 0.63 0.43 0.13 0.29 0.00 0.00 0.00 0.13
(0.7) (0.5) (0.4) (0.5) (0) (0) (0) (0.4)
Staffing during short-term use of extended hours 0.40 0.38 0.00 0.00 0.00 0.10 0.20 0.00
(0.8) (0.5) (0) (0) (0) (0.2) (0.4) (0)
meeting the 1 month target for all patients and all reported sufficient capacity to accommodate fluctuations in patient numbers. Availability of service continuity linear accelerators Departments were asked if they had a dedicated service continuity linear accelerator primarily used to cover machine servicing and QA and unscheduled downtime. The question was answered by 79.0% (n ¼ 49). It was found that 22.4% (n ¼ 11) did have a service continuity machine, including two of the departments that had never used extended working hours (the third department did not complete the question). A service continuity linear accelerator was in 10.3% (n ¼ 3) of departments that were working extended hours and in 40% (n ¼ 8) of departments that were not working extended hours. It should be noted that five departments (10.2%) with a service continuity machine had one by default. Three departments reported not having enough staff in the department to keep all the linear accelerators open full time and therefore had had to close one machine and use it for support. A further two departments reported their service continuity linear accelerators were in fact old machines that had been replaced but never taken out. They were thus being used until a major breakdown, at which point they would be decommissioned.
Servicing and Quality Assurance The return rate for the servicing and QA spreadsheet was 53.3% (n ¼ 32). A summary of the data can be seen in Table 7. The analysis represents 156 linear accelerators. It should be noted that the method of recording scheduled downtime varies between departments. As a consequence, some elements may be included in different categories (e.g. annual servicing is scheduled throughout the year and therefore included in monthly servicing). Over the course of a year, the mean amount of time spent on servicing and QA (excluding daily checks) was 247.2 h per machine (range 129.1e429.5 h). The mean
218
CLINICAL ONCOLOGY
Table 6 e Criteria used by 19 departments that select patients for appointments during extended hours Criterion
No. (%)
Age Diagnosis Performance status Proximity to department Transport Patient stated preference
8 8 6 9 16 7
(42.1) (42.1) (31.6) (47.4) (84.2) (36.8)
(n ¼ 167) of patients said they could make alternative arrangements if their normal mode of transport could not get them to the appointment on time and 16% (n ¼ 74) were unsure. For reasonable appointment times after 5.00 pm, 41.2% (n ¼ 189) of patients said they could make alternative arrangements and 15% (n ¼ 69) were unsure. When asked if patients would want to come to a reasonable appointment time outside of the normal working day, 29% (n ¼ 136) said ‘yes’ and 11.8% (n ¼ 55) were unsure.
Comparison of Methods of Extended Hours Working
Respondents could select more than one criterion.
number of out of hours servicing and QA was 86.6 h per machine (range 0e261 h). This was equivalent to a mean of 35.2% (range 0e100%) of all servicing and QA work being scheduled out of hours. Three departments (9.4%) did all servicing and QA (including daily checks) during the normal working week. This increased to six departments (18.8%) when excluding daily checks. Weekday working outside of normal working hours represented 22.3% of all the machine work. Fourteen (43.8%) departments scheduled work at the weekend and this accounted for 12.7% of all the machine work.
Patient Choice Ninety-one questionnaires were returned from Centre A, 221 from Centre B, 64 from Centre C and 95 from Centre D. One questionnaire was rejected, giving a total of 470. On the day of the survey, 93.5% (n ¼ 429) patients had appointments between 9.00 am and 5.00 pm, 4.8% (n ¼ 22) before 9.00 am and 1.7% (n ¼ 8) between 5.00 pm and 6.00 pm. There were no appointments after 6.00 pm. With regard to patient choice, 58.9% (n ¼ 274) of patients had not been able to choose the approximate time of their appointments and 7.3% (n ¼ 34) were unsure. Table 8 shows the normal mode of transport to a radiotherapy appointment. Figure 2 shows that the most popular preference for radiotherapy appointments was during the normal working day. Outside normal working hours, 8.00e9.00 am (21.7%) and 5.00e6.00 pm (13.0%) were the most accepted. If appointed at a reasonable time before 9.00 am, 36.2%
Table 9 compares five arrangements for extended hours working to the normal working day. The length of the working day reflects the times patients are willing to attend for treatment resulting from the patient survey and includes only the radiographers working on the linear accelerator. All models reflect a 37.5 h working week, which has been implemented across the National Health Service under Agenda for Change. A 1 h lunch break and a 30 min break can be scheduled to ensure all staff work no longer than 4 h without a break and that there are never less than two people on a machine. Routsis and Thomas [14] used a 12% drop in throughput whenever there are only two radiographers on a machine. The same method has been used to compare the efficiency of shift patterns with a 4 day working week. Potential fractions per day reflect the most fractions that would be expected for a constant rate of 4.5 fractions/h for the entire working day [15]. Net fractions per day reflect the anticipated drop in throughput as a result of the working hours when there are only two radiographers on the machine. For ease of comparison between the two methods of working, all staff costs are based on the midpoint of band 6, the expected grading for Senior II radiographers under Agenda for Change [16].
Discussion There is considerable experience of extended working hours throughout the UK. Ninety-five per cent of all responding departments had experience of using extended working
Table 7 e Mean number of hours for servicing and quality assurance (QA) for 32 physics departments (mean [range]) Weekdays Before 9.00 am Daily checks Weekly checks Monthly QC checks Monthly servicing Annual servicing Annual QA QC, quality control.
0.57 0.31 0.11 0.32 1.83 0.12
(0e1.5) (0e2.0) (0e1.0) (0e2.0) (0e24.0) (0e2.0)
9.00 ame5.00 pm 0.07 0.43 4.32 2.97 31.48 18.99
(0e0.5) (0e3.5) (0e26.0) (0e8.3) (0e112.0) (0e317.5)
Weekend After 5.00 pm 0 0.24 1.22 0.15 1.79 1.05
(0) (0e4.5) (0e8.0) (0e1.5) (0e18.0) (0e19.2)
Saturday 0.3 0.22 0.31 0.45 3.19 3.56
(0e0.9) (0e5.0) (0e3.0) (0e4.0) (0e40.0) (0e36.0)
Sunday 0.3 0 0.13 0.00 2.26 0.25
(0e0.9) (0) (0e4.0) (0) (0e34.3) (0e8.0)
EXTENDED HOURS WORKING IN RADIOTHERAPY IN THE UK Table 8 e Patients’ normal mode of transport to radiotherapy appointments Mode
Total (%)
Private taxi Hospital ambulance Volunteer car Self-driven Family/friend Public transport Cycled/walked
10 49 109 85 121 83 8
(2.2) (10.5) (23.4) (18.3) (26.0) (17.8) (1.7)
hours. At present, 19 departments have used the alternative working arrangement for longer than a year and 86% of departments that used extended hours as part of a shortterm initiative were successful in achieving the objectives for moving to a longer working day. However, it is significant that one-third of these departments stated that they would not be able to implement extended hours again without an increase in staff and the radiotherapy budget. The adoption of shift working or a 4 day week is essential for sustained use of extended working days. Comparisons of the various models of working extended hours show that model 3 (Table 9) is the most cost-effective, giving a 31% increase in fractions at a cost increase of only 1.8% per fraction. This model uses four radiographers each working two shifts and extends the working day by 1 h at the start of the day and 2 h at the end of the day, to give an 11.5 h day. This is a shift pattern that has been shown to be sustainable over a prolonged period of time. However, it provides only two radiographers on the machine for 78% of the day and whereas this is adequate for safe routine daily treatment, there is no allowance for service development or the learning of new techniques, a process that is essential in any modern department. Separate allowance would need to be made for these needs. This pattern of working is acceptable to patients who are unwilling to travel for treatment either extremely early in the morning or late at night and although it extends the working day for physics
20.00 - 21.00 19.00 - 20.00 18.00 - 19.00 17.00 - 18.00 12.00 - 17.00 09.00 - 12.00 08.00 - 09.00 07.00 - 08.00 0%
20%
40%
60%
80%
(%) Fig. 2 e Patient preference for the time of their appointment.
219
and technical support staff, the prolongation of their working day is not extreme. Adequate management planning is essential if these altered models of working are to be sustained over a prolonged period or taken as routine. Alternatives to the standard 5 day working week should be considered. A 4 day week involves an individual working their contracted hours over 4 days, rather than 5 days, with a rolling day off. The principle is the same for the 9 day fortnight. Shifts and 4 day working both have an element of antisocial hours, with attendant difficulties in child care. However, shifts do not have the benefit of a rolling day off. The 4 day week is popular with most radiographers in departments that have chosen this option. The short week that results from 4 day week working means less travelling time and therefore less expense and is particularly popular for staff who travel long distances to work. For staff who drive to work, it also facilitates easier parking as the hour of arrival is before the rest of the hospital becomes busy. The questionnaire showed that most radiographers and medical physics staff travel to work by car, so these are important considerations. The rolling day off also allows the scheduling of errands and personal appointments without the need to take a day’s annual leave. Conversely, this results in an accumulation of annual leave to be used up at the end of the year. Where shift working is selected as the working pattern, most staff prefer early rather than late shifts, particularly in the winter, thus avoiding the need to travel home in the dark. The intrinsic disadvantage of the 4 day week is the resulting length of the day that an individual must work. A 37.5 h week over 4 days gives an effective working day of 10.4 h (including 1 h for lunch). Staff working a 4 day week generally did not perceive this as a problem, except when the rolling day off came at the end of four consecutive days of working. The effect is mitigated in the 9 day fortnight where the length of the day is only increased by 9.8% compared with 22.1% with the 4 day week. When working a 4 day week, it is essential that staff take full advantage of scheduled breaks. Long working hours as part of a 4 day week may lead to reduced concentration at the end of the working day and utilising this method of working without enforcing breaks might well result in increased errors, particularly with inputting data and checking. A reasonable scheduling of shifts can ensure that staff work an acceptable span and is unlikely to result in increased sickness levels or stress normally associated with working more unsociable hours. It is also easier to adapt shift times to accommodate changes in patient numbers or machine breakdowns, but it is not so easy to do with a 4 day week as staff are already individually working a long day. Our comparison of the two working arrangements shows shift working to be more cost-effective than a 4 day week for organising radiographer staff. An alternative to lengthening the day is a longer week. It is unlikely that staff groups would opt to work on Sundays, but using Saturday as a sixth day is an option if patients are able to attend. For this to be effective, the department would have to be open for a significant part of the day and
21.8 10.55 36.9 49.0 0.46 4 51.2 11.38 8.00 ame7.20 pm Model 4
Model 3b
Model 3
Model 2
WTE, whole time equivalent.
5
19.2 10.32 39.9 50.1 0.45 3 51.8 11.5 8.00 ame7.30 pm 5
1.8 8.82 31.0 46.9 0.38 9 51.8 11.5 8.00 ame7.30 pm 4
27.9 11.08 30.4 46.7 0.39 0 46.7 10.38 8.00 ame6.20 pm 5
8.66 9.29 e 24.6 35.8 44.6 0.38 0.40 4.5 5 38.3 47.3 8.5 10.5 9.00 ame5.30 pm 8.00 ame6.30 pm 3 4
e Shift working (2 shifts) 4 day week (1 shift) Shift working (2 shifts) Shift working (3 shifts) 4 day week (2 shifts)
Time Method
Number of WTE Work pattern
Normal Model 1
Radiographer cost/fraction (£) Capacity increase (%) Net fractions/ day Potential fractions/day
Machine hours with two staff
Efficiency (radiographers/ treatment hour) Length of day (h)
Table 9 e A comparison of different working arrangements to extend the working day
e 7.3
CLINICAL ONCOLOGY Cost increase (%)
220
ideally should include all members of staff and peripheral services. It would not be cost-effective or good governance to open a department just for a few hours using a skeleton staff. However, a sixth day would also potentially require a 20% increase in staff on every machine working the additional day. The existing problems with recruitment are widely reported. It must also be remembered that perhaps only one-third of radiographers in a department actually run machines. Others perform equally vital supporting roles, such as patient treatment verification (increasingly important with more complex modalities), transcribing and checking, simulation, dosimetry and patient support and information. Traditionally the number of radiographers has been tied to the number of machines in a department, but with the advent of skill mix or role diversification it may be more appropriate to calculate the numbers of radiographers in a department by analysing the number required for specific, different roles. A recent report calculated a benchmark figure of 1.33 whole time equivalent staff (including radiographic assistants, assistant practitioners, etc.) as a minimum for each hour of linear accelerator operation for core service activities [17]. An important consideration is the number of machines that will be involved and the number of additional hours they will work. This depends on how much additional capacity is required, balanced with the number of available staff and the number of patients who are able and willing to attend out of hours. The questionnaires showed that some departments are running a short extension on several machines, whereas others are working a much longer day on just one or two machines. Clearly, spreading the additional workload across several machines is only an option for larger departments. However, a department that operates extended hours on most machines risks problems when a machine breaks down. There is less flexibility to maintain treatment continuity as there will be more patients to redistribute and less available time in the day in which to reschedule. Interruptions to planned radical courses of treatment have been shown to worsen outcomes and should be avoided at all costs [18]. Techniques to adjust radical radiotherapy for unavoidable interruptions and to compensate for gaps have been described [18e20]. Additional costs will, of course, not just be limited to radiographers. The delivery of radiotherapy is multidisciplinary and the delivery of a safe, efficient and wellsupported service involves several professional groups, both clinical and non-clinical. If a compromise is made on the professional mix available during extended hours, some patients are in effect being offered a second-class service. Furthermore, the absence of one professional group increases pressures on another. The hours adopted by radiographers, and even the means by which the hours are managed, should be reflected in the working patterns of physicists, engineers, treatment planners, medical staff, nurses and clerical workers. This is the only way that extended hours working can be robust. The staffing figures show that the burden of existing extended hours working is currently restricted to radiographers. Staff from all clinical
EXTENDED HOURS WORKING IN RADIOTHERAPY IN THE UK
grades should also be involved to ensure that the necessary experience and expertise is on hand. Clinical superintendents, a small staff group, are particularly at risk of being placed under pressure by extended hours working, as they must be available to supervise extended days and will probably pick up the workload of absent staff groups. Staff have been shown to account for about 50% of the costs of operating a radiotherapy department [21]. To implement a longer working day across radiotherapy services would incur substantial increases in payroll costs, whether through overtime or an increase in staff. The additional expense would be offset by capital saving, through greater use of the building and of the linear accelerators. Extended hours working would maximise the return on the costly investment by making the most of the infrastructure during its useful lifespan. Yet Dunscombe et al. [22] showed only a minor saving in the cost per treatment course through extended hours working, even when staff were organised so that overtime payments did not need to be made. The authors noted there was no cost saving in terms of direct materials or administrative overheads. Furthermore, their analysis was limited to the delivery of radiotherapy and did not include support services or personnel. There is unlikely to be any savings with regard to utility consumption, as most hospitals measure department energy usage for recharge purposes. To offer a full service across the entirety of an extended day would require support from radiology, pharmacy and pathology. Our data show that this is difficult for many departments that are regularly working extended hours. This issue, as with direct medical support, is being minimised by selecting fitter patients who have already begun treatment. Should any of these patients require medical attention, a visit to the pharmacy, blood tests or X-rays, they have to make additional visits during the normal working day. Facilities such as security, portering, and refreshments are also a consideration. Good patient care begins when a patient enters a department and while they are waiting for treatment. Hospital departments should always be a secure and welcoming environment regardless of the time of the appointment. The survey of hours of machine servicing and QA showed a large range in the scheduled downtime between different departments. The way in which this was organised seemed to depend on local factors, such as the availability, expertise and motivation of technical staff and how much QA was deemed necessary. A department’s approach to QA may also be affected by past events, such as adverse incidents and their outcome. A recent RCR/Institute of Physics and Engineering in Medicine/Society and College of Radiographers report on radiotherapy QA recommends that the frequency of linear accelerator QA should not be reduced without a full risk analysis, as in many cases reducing the frequency of checks will lead to increased risks of incidents, and will not be cost-effective [23]. Furthermore, routine extended hours working would require radiotherapy departments to have compatible machines to facilitate direct transfer of patients should a breakdown occur.
221
Servicing and QA carried out during the normal working day accounted for an average of about 161 h/year on each linear accelerator. Moving all maintenance out of hours (were possible) might allow a significant increase in capacity without increasing the length of the working day, but this simply shifts the problem on to another workgroup that also has a limited workforce from which to draw. It has to be remembered that although a linear accelerator could be run for 11.5 h by two radiographer shifts, it is probable that radiotherapy physics would need to use three shifts, as at least an additional hour would be required for support before and/or after the treatment hours. The working day would be longer still if a machine broke down and was to be made ready before the next treatment day. The rhythms of our society are relatively fixed and tend to become more rigid as we get older. Our patient questionnaire showed that more patients were willing to come for treatment very early in the morning than would consider leaving the house for treatment after their evening meal. As many patients travel long distances for treatment this means that most patients prefer to have treatment between 9.00 am and 6.00 pm, thus allowing them to maintain the normal pattern of family life through a 4 or 6 week course of daily treatment. However, two out of five patients would consider appointments outside of the normal working day, showing patient support for a moderate extension to the normal day. An extended day is perhaps at best limited to 8.00 am to 8.00 pm with an anticipated reduction in patient uptake of appointments after 6.00 pm. Consideration for transport to the radiotherapy facility is important. A hospital ambulance or volunteer car was used by 33.9% of patients who responded to our survey. Public transport (including private taxis) was used by 20%. Out of hours hospital transport is an issue for almost all radiotherapy centres in the UK despite being available to other services such as dialysis units. Patients, particularly the elderly, do not wish to travel on public transport very early or very late in the day, especially in the winter. Although public transport is well developed within most city centres, it is not the case in rural areas. However, our initial patient survey focused on city centre departments. In areas where more patients would be expected to drive to their appointments, patient attitudes to out of hours appointments may be significantly different.
Conclusion If extended hours working is to be used successfully it must be fully scoped before implementation. It should be clear how long the extended hours are expected to be in place, how the hours will be organised, which professional groups will be involved and what the expected measurable outcome will be in terms of increased throughput. This will allow for periodic assessment of how effective the extended working hours are in practice. Working through a business case or working paper will provide focus. Sustained use of extended working hours is best achieved by adopting shift patterns that reflect the hours that
222
CLINICAL ONCOLOGY
patients are willing and able to attend. Apart from the costs and strategic difficulties in working more than an 11.5 h working day, our patient survey suggests that there would be little support from patients for a very extended day. Our findings show that two shifts to cover an 11.5 h working day would be the most cost-effective alternative to the normal working day. We have outlined the risks to the continuity of patient care if an attempt is made to work all the machines in a department on this basis; it will then be extremely difficult to transfer patients to another machine in case of breakdown, unless there is a service continuity machine available. For small departments working some machines for longer hours, this is a safe alternative. Acknowledgements. The authors thank all the individuals who participated in the questionnaire surveys and particularly those who facilitated the department visits and administered the patient questionnaire for and on behalf of the project team. The project was funded by a grant from the Department of Health to the Royal College of Radiologists. Author for correspondence: F. Calman, Guy’s and St Thomas’ NHS Foundation Trust, St Thomas’ Hospital, Lambeth Palace Road, London SE1 7EH, UK. Tel: þ44-020-7188-1447; E-mail: frances. [email protected] Received 21 March 2006; received in revised form 6 January 2007; accepted 25 January 2007
References 1 Department of Health. NHS cancer plan. London: Department of Health; 2000. 2 Coles CE, Burgess L, Tan LT. An audit of delays before and during radical radiotherapy for cervical cancer d effect on tumour cure probability. Clin Oncol (R Coll Radiol) 2003;15:47e54. 3 O’Rourke N, Edwards R. Lung cancer treatment waiting times and tumour growth. Clin Oncol (R Coll Radiol) 2000;12:141e144. 4 Joint Council for Clinical Oncology. Reducing delays in cancer treatment: some targets. London: Royal College of Physicians; 1993. 5 Summers E, Williams M. Re-audit of radiotherapy waiting times 2005. London: Royal College of Radiologists, 2006 (http://www. rcr.ac.uk/). 6 National Audit Office. The NHS cancer plan: a progress report. London: Stationary Office; 2005. 7 Board of the Faculty of Clinical Oncology. Equipment, workload and staffing for radiotherapy in the UK, 1997e2002. London: Royal College of Radiologists; 2003.
8 Bentzen SM, Heeren G, Cottier B, et al. Towards evidencebased guidelines for radiotherapy infrastructure and staffing needs in Europe: the ESTRO QUARTS project. Radiother Oncol 2005;75:355e365. 9 Radiotherapy Special Interest Group. Staffing levels and skill mix in UK radiotherapy physics departments. Scope 1997;6: 19e25. 10 Department of Health. The NHS improvement plan: putting people at the heart of public services. London: Department of Health; 2004. 11 cancerimprovement.nhs.uk. Leicester: Cancer Services Collaborative ‘Improvement Partnership’; c2005e06 (http: //www.cancerimprovement.nhs.uk/). 12 Board of the Faculty of Clinical Oncology. Extending the working day for delivery of radiotherapy. London: Royal College of Radiologists; 1997. 13 National Cancer Services Analysis Team. A survey of radiotherapy services in the UK. Clatterbridge: NatCanSAT; 2002. 14 Routsis D, Thomas S, Head J. Are extended working days sustainable in radiotherapy? J Radiother Pract 2006;5:77e85. 15 Delaney GP, Shafiq RJ, Jalaludin BB, Barton MB. Technology enhancements and changes in radiotherapy throughput in New South Wales. Clin Oncol (R Coll Radiol) 2005;17:305e310. 16 nhsemployers.org. London: NHS Confederation; c2005 (http:// www.nhsemployers.org/). 17 College of Radiographers. Radiographic staffing: short term guidance. 2005 benchmark for standard core functions within radiotherapy, 1st edn. London: Society of Radiographers; 2005. 18 Board of the Faculty of Clinical Oncology. Guidelines for the management of unscheduled interruption or prolongation of a radical course of radiotherapy, 2nd edn. London: Royal College of Radiologists; 2002. 19 Dale RG, Hendry JH, Jones B, Robertson AG, Deehan C, Sinclair JA. Practical methods for compensating for missed treatment days in radiotherapy, with particular reference to head and neck schedules. Clin Oncol (R Coll Radiol) 2002;14:382e393. 20 Hendry JH, Bentzen SM, Dale RG, et al. A modelled comparison of the effects of using different ways to compensate for missed treatment days in radiotherapy. Clin Oncol (R Coll Radiol) 1996; 8:297e307. 21 Lievens Y, van den Bogaert W, Kesteloot K. Activity-based costing: a practical model for cost calculation in radiotherapy. Int J Radiat Oncol Biol Phys 2003;57:522e535. 22 Dunscombe P, Roberts G, Walker J. The cost of radiotherapy as a function of facility size and hours of operation. Br J Radiol 1999;72:598e603. 23 McKenzie A, Briggs G, Buchanan R, et al. Balancing costs and benefits of checking in radiotherapy. York: Institute of Physics and Engineering in Medicine; 2006.
Original Article
Extended Hours Working in Radiotherapy in the UK L. White, E. Beckingham, F. Calman, C. Deehan Guy’s and St Thomas’ NHS Foundation Trust, St Thomas’ Hospital, Lambeth Palace Road, London SE1 7EH, UK
ABSTRACT: Aims: To analyse extended hours working patterns within UK cancer centres and to assess alternatives to the normal 9.00 am to 5.00 pm working day. Materials and methods: Questionnaires were sent to 62 radiotherapy managers in June and July 2005 to survey where extended hours working had been implemented, the objectives for using a longer working day and how departments organised their service issues, including staffing levels, costs and patients. This was followed by visits to six departments that were working extended hours. A second questionnaire sent to 60 radiotherapy physics managers in September 2005 requested information for the hours of daily, monthly and annual megavoltage machine servicing and quality assurance (QA). A third questionnaire was distributed to all radiotherapy outpatients from four departments who attended on a single day of survey in 2005. It looked at patient preference for treatment hours. Results: In total, 57 (92%) radiotherapy managers responded. Thirty-one departments (55%) were working extended hours, 22 (39%) had short-term experience and three (5%) departments had no experience. Increasing capacity to reduce waiting lists was the main reason for working extended hours. The additional hours were predominantly worked by radiographers, with little or no support from the other department disciplines. The servicing and QA spreadsheet was returned by 53% (n [ 32) of physicists. The average amount of servicing and Quality Assurance (QA) work being scheduled out of hours in each department was 35% (0e100%). The patient questionnaire was completed by 470 patients. When asked if patients would want to come to a reasonable appointment time outside of the normal working day, 29% (n [ 136) said ‘yes’ and 12% (n [ 55) were unsure. Conclusion: It was concluded that two shifts covering an 11.5 h working day is a robust alternative to the normal working day, taking into consideration efficient use of radiographers and patient preference for out of hours appointments. White, L. et al. (2007). Clinical Oncology 19, 213e222 ª 2007 Published by Elsevier Ltd on behalf of The Royal College of Radiologists. Key words: Capacity and demand, patient choice, radiotherapy, servicing and QA, work patterns
Introduction The NHS cancer plan [1] provided the framework for raising standards in treatment and care and for providing faster more effective cancer services. In December 2005, the plan set the target interval times for all cancers at a maximum of 1 month from the date of the decision to treat to the first definitive treatment and 2 months from an urgent general practitioner referral to the first definitive treatment. The adverse effects of delay in the radical treatment of cancers, particularly for category I patients, have been reported [2,3]. Therefore, the target times are recognised as good practice, and reflect those originally specified by the Joint Council for Clinical Oncology in 1993 [4]. However, the targets come at a time when the maximum recommended waiting interval for radical treatment is being exceeded by 53% of cancer patients in the UK [5]. Increased capacity and a streamlining of services are required to ensure that the targets are met. In England, the NHS cancer plan pledged significant capital investment to replace 42 old machines and to initially install an additional 0936-6555/07/190213þ10 $35.00/0
14 new linear accelerators with a further 45 additional linear accelerators to be delivered over the following 3 years. By 2004, the National Health Service had received 83 linear accelerators, achieving the target of 4.0 linear accelerators per million [6]. In 2003, the Royal College of Radiologists (RCR) published a report providing recommendations on radiotherapy equipment levels and staffing for service planning [7]. The report advised that the target of the NHS cancer plan was no longer relevant and recommended sufficient linear accelerators to achieve a provision equivalent to 5.5e6.0 per million population if departments were to achieve the optimum outcome from modern radiotherapy and have the capacity to reduce waiting times. This was supported by the ESTRO QUARTS project, which calculated an evidence-based best estimate of 6.5 linear accelerators per million population for the UK [8]. The RCR report also warned that the 2003e2006 Government investment programme for linear accelerators in England would only address the problem of out-of-date radiotherapy machines and not increase capacity.
ª 2007 Published by Elsevier Ltd on behalf of The Royal College of Radiologists.
214
CLINICAL ONCOLOGY
Inadequate equipment provision is not the only factor affecting capacity. The problem is compounded nationally by the shortage of qualified radiographers, physicists and technical staff of all grades [7,9] and locally through the inevitable loss of capacity that can result from machine breakdowns, public holidays and staff sickness. As a result, radiotherapy departments have had to look at ways to make further use of the assets already available. For many years, radiotherapy facilities, like most outpatient departments, have based appointment hours around a nominal 9.00 am to 5.00 pm, 5 day working week. One option for an immediate increase in capacity is to extend the working hours. Most departments already have experience of short-term extended hours working to compensate for reduced capacity during machine breakdown or increased demands on the service. More recently, a number of departments have implemented long-term, sustained extended hours working to tackle waiting lists. The use of extended hours is seen as a natural complement to the patient’s choice agenda, which has recently gained momentum [10]. ‘Public patient involvement’ is now an integral part of service development. A key objective of the Cancer Services Collaborative ‘Improvement Partnership’ is to predict patient requirements in advance and pre-plan and pre-schedule care at times to suit them [11]. Extended hours working would therefore seem not only to provide an increase in capacity, but also to have the additional outcome of offering patients a greater range of appointment slots beyond the normal working week. The successful adoption of extended hours working has implications for all aspects of a radiotherapy department. The potential advantages, disadvantages and costs of working an extended day have already been considered in detail in an RCR publication in 1997 [12]. For the current project, data were collected through two questionnaires (to radiotherapy and radiotherapy physics departments) to highlight the use of extended hours working in the UK and to describe how the radiotherapy service was being delivered during the extended hours (Fig. 1). A third questionnaire considered patient preference for radiotherapy appointment times. For departments considering moving to extended hours working or increasing their extended hours, this paper also compares models of extended hours working arrangements for the delivery of radiotherapy services within the National Health Service. For the purpose of this paper, ‘extended hours working’ is defined as hours that are worked to provide regular treatment appointments either before 9.00 am and/or 5.4% Currently working extended hours Short-term experience of working extended hours
39.3% 55.4%
Never used extended hours working
Fig. 1 e Extended hours working in radiotherapy departments in the UK.
after 5.00 pm, Monday to Friday, thus giving a working weekday that is longer than 8 h. This is adjusted for departments that have historically worked from 8.00 am to 4.00 pm. A 36 h week was used as the 37.5 h week under Agenda for Change had not yet been widely implemented in radiotherapy at the time of the survey. Extended hours working includes all hours worked at weekends except those worked to provide Continuous Hyper-fractionated Accelerated RadioTherapy (CHART) or as part of an out of hours on-call arrangement.
Materials and Methods Three independent questionnaires were distributed as part of the data collection to give a global view of radiotherapy practice at that time.
Radiotherapy Questionnaire The first questionnaire was developed with the aim of collecting data on the national use of extended hours working. The questionnaire was mailed in two cohorts in June and July 2005 to the managers of 62 radiotherapy departments in the UK. The 20 departments in the first cohort were selected from the equipment and workforce survey carried out by the National Cancer Service Analysis Team in July 2002 [13]. All of the departments had reported working an extended day in the NatCanSAT survey. The second cohort was sent in July 2005 to the remaining departments. There were no exclusion criteria. The questionnaire was self-administered and applied a filter. Respondents were given 3 weeks to complete the questionnaire. A follow-up telephone call was made at the end of the second week to the 18 managers in cohort 1 and the 24 managers in cohort 2 who had not already replied. Departmental visits The returned questionnaires were used to select six departments from across the UK for local visits. The selected departments were all working extended hours at the time of the visits and were of varying sizes, locations (city centre and out of town) and with different models of extended hours working in operation. The visits were attended by three members of the project team comprising a superintendent radiographer, a senior radiotherapy physicist and the project manager. Unstructured interviews were held with all the staff groups involved in delivering the radiotherapy service and were used to further explore the issues and logistics of maintaining sustained extended hours working.
Radiotherapy Physics Questionnaire The second questionnaire was distributed to departmental heads of radiotherapy physics in September 2005. Information was requested in a spreadsheet format for the hours of daily, monthly and annual megavoltage machine servicing and quality assurance (QA). The data
EXTENDED HOURS WORKING IN RADIOTHERAPY IN THE UK
were divided into work scheduled during the normal working week, during an extended day and at the weekend. The spreadsheet allowed for machines in the same department that follow different maintenance schedules. The questionnaire was distributed by e-mail to 60 heads of radiotherapy physics (two physicists managed services across two centres) with a 1 week deadline.
Patient Questionnaire The third questionnaire was distributed to radiotherapy outpatients from four inner city departments regularly working extended hours. All questions were multiple choice. Every radiotherapy outpatient who attended each of the four centres on the day of survey in December 2005 was asked to complete the questionnaire. The survey was only issued on a single, full day to prevent duplication through patients attending for treatment on consecutive days. Patients were provided with a questionnaire by a member of their radiotherapy team while they waited for treatment. The questionnaire was self-administered. Care was taken to assure patients that participation was voluntary and that all responses were anonymous and would not be used to decide the patient’s own future appointments. Data collected from all three questionnaires were summarised collectively using percentages, means, ranges and standard deviations. Further analysis of the patient data will be provided in a separate communication.
Results Radiotherapy Managers’ Questionnaire The response rate for cohort 1 was 90% (n ¼ 18) and 92.9% (n ¼ 39) for cohort 2. The overall response rate was 91.9%. One returned paper was excluded from the analysis due to inadequate completion. Responses showed that 50% (n ¼ 28) of radiotherapy departments were routinely working extended hours. Three radiotherapy managers did not consider their departments to be operating an extended day when their current machine hours showed otherwise (by the project’s definition of extended hours working). Thus, the actual number of departments that were working extended hours increased to 55.4% (n ¼ 31). However, these departments could not be included in the subsequent analysis due to the filter. Of those departments not routinely working extended hours, 88% (n ¼ 22) had temporarily used the service arrangement. Only 5.4% (n ¼ 3) of all responding radiotherapy departments had never used extended hours working. Departments currently using extended hours working Table 1 shows the two main reasons why radiotherapy departments were using extended hours working. Other reasons included: to accommodate servicing and QA during the normal working day (n ¼ 2), to facilitate radiographer run-ups (n ¼ 1), to accommodate more complex treatments
215
Table 1 e Reasons for the use of extended hours working Reason Increase capacity Equipment replacement Other
No. (%) 23 (82.1) 4 (14.3) 6 (21.4)
(n ¼ 1), to improve recruitment and retention through uplift of radiographer salaries (n ¼ 1) and local Trust-wide terms and conditions regarding staff hours (n ¼ 1). Five departments provided more than one reason. A working paper or formal business case was not produced before implementation by 42.9% (n ¼ 12) of the radiotherapy departments. Extended hours working had been operating for a year or less in 14.3% (n ¼ 4) of departments and between 1 and 5 years in 28.6% (n ¼ 8). Eleven departments (39.3%) had used extended hours for more than 5 years. Table 2 shows how departments were managing the staff costs from operating extended hours working. For the most part, the extended hours were being accommodated through flexible working and time off in lieu with no additional staff costs. The longest working day covered by radiographers was 8.15 am to 9.00 pm. For radiotherapy physics and engineering it was 6.30 am to 9.00 pm. Radiographers were working shifts in 53.6% (n ¼ 15) of radiotherapy departments and 17.9% (n ¼ 5) needed to schedule three shifts in a working day to cover either a 10 h day (n ¼ 4) or a 12 h day (n ¼ 1). A 4 day week (n ¼ 4) or a 9 day fortnight (n ¼ 1) was used by 17.9% of departments. Shift working was used in 25% (n ¼ 7) of radiotherapy physics departments, of which five departments scheduled three shifts in a working day. In departments where both radiographers and radiotherapy physics were working shifts (n ¼ 5), the working day of the radiotherapy physics department was longer by a mean of 1.4 h (range 0e2.5 h) than that of the radiographers. The mean number of additional hours worked each week per department was 15.3 h (range 3e50 h) on a mean of 2.7 machines (range 1e8). In all, 68.6% of the 116 megavoltage machines that were in regular use were being used by departments that operate extended hours working. Across the course of a working week (Monday to Friday), a mean total of 7.0 h (range 0e20 h) was worked before the Table 2 e Department funding of extended hours working Funding Flexible working/shifts Overtime Increased establishment Increased budget 37.5 h week as standard Not stated
No. (%) 20 4 3 1 2 1
(71.4) (14.3) (10.7) (3.6) (7.1) (3.6)
Three departments reported more than one funding mechanism.
216
CLINICAL ONCOLOGY
by 67.9% (n ¼ 19) of departments. A breakdown of the criteria used by these departments is shown in Table 6. Transport was the primary factor, with 84.2% (n ¼ 16) selecting patients who had their own transport. Patients with breast or prostate cancer were generally considered first, whereas patients with complex treatment plans were usually excluded. Patients in a general good state of health and not requiring any additional support were also being selected.
start of the normal working day and a mean of 8.3 h (range 0e35 h) was worked at the end of the normal working day. More than an additional 10 h a week was being worked in 50.0% (n ¼ 14) of radiotherapy departments and 32.1% (n ¼ 9) were operating in excess of an additional 20 h a week. One department reported regularly working at the weekend for routine treatments, running a single machine for 4 h on Saturday morning. Only four departments (14.3%) stopped machines for lunch or breaks and this was due to staff shortages in all instances. Table 3 shows the radiographer staffing for extended hours working. The table does not include departments that were using a 4 day week working pattern, as staffing is constant throughout the day (excluding part-time staff). Typically, each machine was being run by three radiographers with support cover from a clinical superintendent acting as supervisor across all the participating machines. The mean level of support from radiographer helpers and assistant practitioners was low. Table 4 shows the department staffing for all other professions. In nearly all cases, patients who required planning, simulation or the mould room were seen during normal working hours. Although medical support in the department was low, all had on-call support. Access to peripheral services was also low, with 82.1% (n ¼ 23) having access to neither radiology nor pharmacy during extended hours. Hostel accommodation for patients was not offered by 67.9% (n ¼ 19) of departments. Hospital transport also proved difficult, with 82.1% (n ¼ 23) not being able to offer hospital transport before the beginning of the normal working day and 96.4% (n ¼ 27) unable to offer transport after the end of the normal working day. Table 5 shows the terms and conditions of radiographers and radiotherapy physics staff who worked extended hours. It can be seen that despite there rarely being a financial incentive to participate in extended working hours, staff in both groups were expected to participate. Eight radiotherapy departments (28.6%) formally consulted their patients as part of the decision to introduce extended hours working. Of these centres, all found patients were willing to come as early as 8.00 am. The latest patients were willing to attend ranged from 4.30 pm to 8.30 pm. However, 8.00 pm was the most common (n ¼ 3). Preferred selection criteria to book specific patients to the appointment slots during the extended hours were used
Departments that have short-term experience of extended hours working It was found that 39.3% (n ¼ 22) of responding departments had short-term experience of extended hours working, but were using normal working hours when the questionnaire was distributed. The most common objective for short-term use of extended hours was to reduce waiting lists. This applied to 50% (n ¼ 11) of departments. Extended hours during machine maintenance was cited by 36.4% (n ¼ 8) and during linear accelerator replacement by 27.3% (n ¼ 6). Four departments gave more than one objective and one department did not state an objective. Most departments that used extended hours working in the short term incurred additional radiographer costs. Overtime payments were paid by 68.2% (n ¼ 15) of responding departments. Only three departments received supplementary short-term funding through local initiative schemes to support the additional costs. The mean number of megavoltage units used for the short-term use of extended hours working was 1.7 (range 1e5). The mean number of additional hours was 3.1 (range 0.5e4.25 h) per day. The staffing allocation can be seen in Tables 3 and 4. No departments included planning, simulator or mould room services as part of the short-term use. Two departments (9%) had medical support during the extended hours and five (22.7%) had nursing support. None of the departments had administrative and clerical support. Only three departments (13.6%) failed to achieve their objectives for the introduction of short-term use of extended hours. Two departments reported finding it difficult to sustain the extended hours working with the number of staff in the department. The third department found that the throughput of patients was limited by simulator capacity. Thirty-two per cent (n ¼ 7) of the
Table 3 e Radiographer staffing per machine during extended working hours (mean [standard deviation])
Staff grade Senior radiographers Radiographers Assistant practitioners Radiographer helpers
All departments regularly working extended hours (n ¼ 28) 1.58 1.37 0.17 0.25
(0.7) (0.7) (0.4) (0.4)
Departments regularly working more than 10 additional hours per week (n ¼ 14) 1.65 1.70 0.14 0.20
(0.7) (0.7) (0.5) (0.4)
Departments regularly working more than 20 additional hours per week (n ¼ 9) 1.58 1.67 0.21 0.17
(0.8) (0.8) (0.6) (0.4)
Staffing during short-term use of extended hours 1.81 1.35 0.05 0.27
(0.9) (0.7) (0.2) (0.5)
EXTENDED HOURS WORKING IN RADIOTHERAPY IN THE UK
217
Table 4 e Non-radiographer staffing during extended working hours (mean [standard deviation])
Profession Physicists Technicians Planning Simulator Mould room Medical Nursing Administration and clerical
All departments regularly working extended hours (n ¼ 28) 0.57 0.63 0.15 0.34 0.10 0.36 0.22 0.29
Departments regularly working more than 10 additional hours per week (n ¼ 14)
(0.8) (0.6) (0.4) (0.7) (0.3) (0.6) (0.5) (0.5)
0.64 0.50 0.08 0.55 0.10 0.00 0.20 0.17
departments who had used extended hours successfully noted they would be unable to use extended hours again due to the lack of staff and additional funding to support it. Three departments (13.6%) reported that extended hours working would probably be reintroduced in the next 12 months to meet the cancer targets.
Departments that have never implemented extended hours working Three responding departments (5.4%) had never used extended working hours. All three departments reported Table 5 e Terms and conditions and access to workplace for 28 departments working extended hours Radiographers
Physics
Yes (%) Terms and conditions Were staff consulted? Is it in their contract of employment? Is it voluntary? Is it expected that they will participate? Is there a financial incentive? Access to workplace Do most staff live locally? Do most staff use public transport? Do most staff use their own transport? Is there designated parking available? Are there cre `che facilities available?
93.8 70.6
88.9 57.9
55.9 82.9
61.8 88.2
25.7
29.4
48.6
50.0
21.6
18.9
83.8
89.2
48.6
60.0
48.6
33.3
(0.7) (0.5) (0.3) (0.8) (0.3) (0) (0.4) (0.4)
Departments regularly working more than 20 additional hours per week (n ¼ 9) 0.63 0.43 0.13 0.29 0.00 0.00 0.00 0.13
(0.7) (0.5) (0.4) (0.5) (0) (0) (0) (0.4)
Staffing during short-term use of extended hours 0.40 0.38 0.00 0.00 0.00 0.10 0.20 0.00
(0.8) (0.5) (0) (0) (0) (0.2) (0.4) (0)
meeting the 1 month target for all patients and all reported sufficient capacity to accommodate fluctuations in patient numbers. Availability of service continuity linear accelerators Departments were asked if they had a dedicated service continuity linear accelerator primarily used to cover machine servicing and QA and unscheduled downtime. The question was answered by 79.0% (n ¼ 49). It was found that 22.4% (n ¼ 11) did have a service continuity machine, including two of the departments that had never used extended working hours (the third department did not complete the question). A service continuity linear accelerator was in 10.3% (n ¼ 3) of departments that were working extended hours and in 40% (n ¼ 8) of departments that were not working extended hours. It should be noted that five departments (10.2%) with a service continuity machine had one by default. Three departments reported not having enough staff in the department to keep all the linear accelerators open full time and therefore had had to close one machine and use it for support. A further two departments reported their service continuity linear accelerators were in fact old machines that had been replaced but never taken out. They were thus being used until a major breakdown, at which point they would be decommissioned.
Servicing and Quality Assurance The return rate for the servicing and QA spreadsheet was 53.3% (n ¼ 32). A summary of the data can be seen in Table 7. The analysis represents 156 linear accelerators. It should be noted that the method of recording scheduled downtime varies between departments. As a consequence, some elements may be included in different categories (e.g. annual servicing is scheduled throughout the year and therefore included in monthly servicing). Over the course of a year, the mean amount of time spent on servicing and QA (excluding daily checks) was 247.2 h per machine (range 129.1e429.5 h). The mean
218
CLINICAL ONCOLOGY
Table 6 e Criteria used by 19 departments that select patients for appointments during extended hours Criterion
No. (%)
Age Diagnosis Performance status Proximity to department Transport Patient stated preference
8 8 6 9 16 7
(42.1) (42.1) (31.6) (47.4) (84.2) (36.8)
(n ¼ 167) of patients said they could make alternative arrangements if their normal mode of transport could not get them to the appointment on time and 16% (n ¼ 74) were unsure. For reasonable appointment times after 5.00 pm, 41.2% (n ¼ 189) of patients said they could make alternative arrangements and 15% (n ¼ 69) were unsure. When asked if patients would want to come to a reasonable appointment time outside of the normal working day, 29% (n ¼ 136) said ‘yes’ and 11.8% (n ¼ 55) were unsure.
Comparison of Methods of Extended Hours Working
Respondents could select more than one criterion.
number of out of hours servicing and QA was 86.6 h per machine (range 0e261 h). This was equivalent to a mean of 35.2% (range 0e100%) of all servicing and QA work being scheduled out of hours. Three departments (9.4%) did all servicing and QA (including daily checks) during the normal working week. This increased to six departments (18.8%) when excluding daily checks. Weekday working outside of normal working hours represented 22.3% of all the machine work. Fourteen (43.8%) departments scheduled work at the weekend and this accounted for 12.7% of all the machine work.
Patient Choice Ninety-one questionnaires were returned from Centre A, 221 from Centre B, 64 from Centre C and 95 from Centre D. One questionnaire was rejected, giving a total of 470. On the day of the survey, 93.5% (n ¼ 429) patients had appointments between 9.00 am and 5.00 pm, 4.8% (n ¼ 22) before 9.00 am and 1.7% (n ¼ 8) between 5.00 pm and 6.00 pm. There were no appointments after 6.00 pm. With regard to patient choice, 58.9% (n ¼ 274) of patients had not been able to choose the approximate time of their appointments and 7.3% (n ¼ 34) were unsure. Table 8 shows the normal mode of transport to a radiotherapy appointment. Figure 2 shows that the most popular preference for radiotherapy appointments was during the normal working day. Outside normal working hours, 8.00e9.00 am (21.7%) and 5.00e6.00 pm (13.0%) were the most accepted. If appointed at a reasonable time before 9.00 am, 36.2%
Table 9 compares five arrangements for extended hours working to the normal working day. The length of the working day reflects the times patients are willing to attend for treatment resulting from the patient survey and includes only the radiographers working on the linear accelerator. All models reflect a 37.5 h working week, which has been implemented across the National Health Service under Agenda for Change. A 1 h lunch break and a 30 min break can be scheduled to ensure all staff work no longer than 4 h without a break and that there are never less than two people on a machine. Routsis and Thomas [14] used a 12% drop in throughput whenever there are only two radiographers on a machine. The same method has been used to compare the efficiency of shift patterns with a 4 day working week. Potential fractions per day reflect the most fractions that would be expected for a constant rate of 4.5 fractions/h for the entire working day [15]. Net fractions per day reflect the anticipated drop in throughput as a result of the working hours when there are only two radiographers on the machine. For ease of comparison between the two methods of working, all staff costs are based on the midpoint of band 6, the expected grading for Senior II radiographers under Agenda for Change [16].
Discussion There is considerable experience of extended working hours throughout the UK. Ninety-five per cent of all responding departments had experience of using extended working
Table 7 e Mean number of hours for servicing and quality assurance (QA) for 32 physics departments (mean [range]) Weekdays Before 9.00 am Daily checks Weekly checks Monthly QC checks Monthly servicing Annual servicing Annual QA QC, quality control.
0.57 0.31 0.11 0.32 1.83 0.12
(0e1.5) (0e2.0) (0e1.0) (0e2.0) (0e24.0) (0e2.0)
9.00 ame5.00 pm 0.07 0.43 4.32 2.97 31.48 18.99
(0e0.5) (0e3.5) (0e26.0) (0e8.3) (0e112.0) (0e317.5)
Weekend After 5.00 pm 0 0.24 1.22 0.15 1.79 1.05
(0) (0e4.5) (0e8.0) (0e1.5) (0e18.0) (0e19.2)
Saturday 0.3 0.22 0.31 0.45 3.19 3.56
(0e0.9) (0e5.0) (0e3.0) (0e4.0) (0e40.0) (0e36.0)
Sunday 0.3 0 0.13 0.00 2.26 0.25
(0e0.9) (0) (0e4.0) (0) (0e34.3) (0e8.0)
EXTENDED HOURS WORKING IN RADIOTHERAPY IN THE UK Table 8 e Patients’ normal mode of transport to radiotherapy appointments Mode
Total (%)
Private taxi Hospital ambulance Volunteer car Self-driven Family/friend Public transport Cycled/walked
10 49 109 85 121 83 8
(2.2) (10.5) (23.4) (18.3) (26.0) (17.8) (1.7)
hours. At present, 19 departments have used the alternative working arrangement for longer than a year and 86% of departments that used extended hours as part of a shortterm initiative were successful in achieving the objectives for moving to a longer working day. However, it is significant that one-third of these departments stated that they would not be able to implement extended hours again without an increase in staff and the radiotherapy budget. The adoption of shift working or a 4 day week is essential for sustained use of extended working days. Comparisons of the various models of working extended hours show that model 3 (Table 9) is the most cost-effective, giving a 31% increase in fractions at a cost increase of only 1.8% per fraction. This model uses four radiographers each working two shifts and extends the working day by 1 h at the start of the day and 2 h at the end of the day, to give an 11.5 h day. This is a shift pattern that has been shown to be sustainable over a prolonged period of time. However, it provides only two radiographers on the machine for 78% of the day and whereas this is adequate for safe routine daily treatment, there is no allowance for service development or the learning of new techniques, a process that is essential in any modern department. Separate allowance would need to be made for these needs. This pattern of working is acceptable to patients who are unwilling to travel for treatment either extremely early in the morning or late at night and although it extends the working day for physics
20.00 - 21.00 19.00 - 20.00 18.00 - 19.00 17.00 - 18.00 12.00 - 17.00 09.00 - 12.00 08.00 - 09.00 07.00 - 08.00 0%
20%
40%
60%
80%
(%) Fig. 2 e Patient preference for the time of their appointment.
219
and technical support staff, the prolongation of their working day is not extreme. Adequate management planning is essential if these altered models of working are to be sustained over a prolonged period or taken as routine. Alternatives to the standard 5 day working week should be considered. A 4 day week involves an individual working their contracted hours over 4 days, rather than 5 days, with a rolling day off. The principle is the same for the 9 day fortnight. Shifts and 4 day working both have an element of antisocial hours, with attendant difficulties in child care. However, shifts do not have the benefit of a rolling day off. The 4 day week is popular with most radiographers in departments that have chosen this option. The short week that results from 4 day week working means less travelling time and therefore less expense and is particularly popular for staff who travel long distances to work. For staff who drive to work, it also facilitates easier parking as the hour of arrival is before the rest of the hospital becomes busy. The questionnaire showed that most radiographers and medical physics staff travel to work by car, so these are important considerations. The rolling day off also allows the scheduling of errands and personal appointments without the need to take a day’s annual leave. Conversely, this results in an accumulation of annual leave to be used up at the end of the year. Where shift working is selected as the working pattern, most staff prefer early rather than late shifts, particularly in the winter, thus avoiding the need to travel home in the dark. The intrinsic disadvantage of the 4 day week is the resulting length of the day that an individual must work. A 37.5 h week over 4 days gives an effective working day of 10.4 h (including 1 h for lunch). Staff working a 4 day week generally did not perceive this as a problem, except when the rolling day off came at the end of four consecutive days of working. The effect is mitigated in the 9 day fortnight where the length of the day is only increased by 9.8% compared with 22.1% with the 4 day week. When working a 4 day week, it is essential that staff take full advantage of scheduled breaks. Long working hours as part of a 4 day week may lead to reduced concentration at the end of the working day and utilising this method of working without enforcing breaks might well result in increased errors, particularly with inputting data and checking. A reasonable scheduling of shifts can ensure that staff work an acceptable span and is unlikely to result in increased sickness levels or stress normally associated with working more unsociable hours. It is also easier to adapt shift times to accommodate changes in patient numbers or machine breakdowns, but it is not so easy to do with a 4 day week as staff are already individually working a long day. Our comparison of the two working arrangements shows shift working to be more cost-effective than a 4 day week for organising radiographer staff. An alternative to lengthening the day is a longer week. It is unlikely that staff groups would opt to work on Sundays, but using Saturday as a sixth day is an option if patients are able to attend. For this to be effective, the department would have to be open for a significant part of the day and
21.8 10.55 36.9 49.0 0.46 4 51.2 11.38 8.00 ame7.20 pm Model 4
Model 3b
Model 3
Model 2
WTE, whole time equivalent.
5
19.2 10.32 39.9 50.1 0.45 3 51.8 11.5 8.00 ame7.30 pm 5
1.8 8.82 31.0 46.9 0.38 9 51.8 11.5 8.00 ame7.30 pm 4
27.9 11.08 30.4 46.7 0.39 0 46.7 10.38 8.00 ame6.20 pm 5
8.66 9.29 e 24.6 35.8 44.6 0.38 0.40 4.5 5 38.3 47.3 8.5 10.5 9.00 ame5.30 pm 8.00 ame6.30 pm 3 4
e Shift working (2 shifts) 4 day week (1 shift) Shift working (2 shifts) Shift working (3 shifts) 4 day week (2 shifts)
Time Method
Number of WTE Work pattern
Normal Model 1
Radiographer cost/fraction (£) Capacity increase (%) Net fractions/ day Potential fractions/day
Machine hours with two staff
Efficiency (radiographers/ treatment hour) Length of day (h)
Table 9 e A comparison of different working arrangements to extend the working day
e 7.3
CLINICAL ONCOLOGY Cost increase (%)
220
ideally should include all members of staff and peripheral services. It would not be cost-effective or good governance to open a department just for a few hours using a skeleton staff. However, a sixth day would also potentially require a 20% increase in staff on every machine working the additional day. The existing problems with recruitment are widely reported. It must also be remembered that perhaps only one-third of radiographers in a department actually run machines. Others perform equally vital supporting roles, such as patient treatment verification (increasingly important with more complex modalities), transcribing and checking, simulation, dosimetry and patient support and information. Traditionally the number of radiographers has been tied to the number of machines in a department, but with the advent of skill mix or role diversification it may be more appropriate to calculate the numbers of radiographers in a department by analysing the number required for specific, different roles. A recent report calculated a benchmark figure of 1.33 whole time equivalent staff (including radiographic assistants, assistant practitioners, etc.) as a minimum for each hour of linear accelerator operation for core service activities [17]. An important consideration is the number of machines that will be involved and the number of additional hours they will work. This depends on how much additional capacity is required, balanced with the number of available staff and the number of patients who are able and willing to attend out of hours. The questionnaires showed that some departments are running a short extension on several machines, whereas others are working a much longer day on just one or two machines. Clearly, spreading the additional workload across several machines is only an option for larger departments. However, a department that operates extended hours on most machines risks problems when a machine breaks down. There is less flexibility to maintain treatment continuity as there will be more patients to redistribute and less available time in the day in which to reschedule. Interruptions to planned radical courses of treatment have been shown to worsen outcomes and should be avoided at all costs [18]. Techniques to adjust radical radiotherapy for unavoidable interruptions and to compensate for gaps have been described [18e20]. Additional costs will, of course, not just be limited to radiographers. The delivery of radiotherapy is multidisciplinary and the delivery of a safe, efficient and wellsupported service involves several professional groups, both clinical and non-clinical. If a compromise is made on the professional mix available during extended hours, some patients are in effect being offered a second-class service. Furthermore, the absence of one professional group increases pressures on another. The hours adopted by radiographers, and even the means by which the hours are managed, should be reflected in the working patterns of physicists, engineers, treatment planners, medical staff, nurses and clerical workers. This is the only way that extended hours working can be robust. The staffing figures show that the burden of existing extended hours working is currently restricted to radiographers. Staff from all clinical
EXTENDED HOURS WORKING IN RADIOTHERAPY IN THE UK
grades should also be involved to ensure that the necessary experience and expertise is on hand. Clinical superintendents, a small staff group, are particularly at risk of being placed under pressure by extended hours working, as they must be available to supervise extended days and will probably pick up the workload of absent staff groups. Staff have been shown to account for about 50% of the costs of operating a radiotherapy department [21]. To implement a longer working day across radiotherapy services would incur substantial increases in payroll costs, whether through overtime or an increase in staff. The additional expense would be offset by capital saving, through greater use of the building and of the linear accelerators. Extended hours working would maximise the return on the costly investment by making the most of the infrastructure during its useful lifespan. Yet Dunscombe et al. [22] showed only a minor saving in the cost per treatment course through extended hours working, even when staff were organised so that overtime payments did not need to be made. The authors noted there was no cost saving in terms of direct materials or administrative overheads. Furthermore, their analysis was limited to the delivery of radiotherapy and did not include support services or personnel. There is unlikely to be any savings with regard to utility consumption, as most hospitals measure department energy usage for recharge purposes. To offer a full service across the entirety of an extended day would require support from radiology, pharmacy and pathology. Our data show that this is difficult for many departments that are regularly working extended hours. This issue, as with direct medical support, is being minimised by selecting fitter patients who have already begun treatment. Should any of these patients require medical attention, a visit to the pharmacy, blood tests or X-rays, they have to make additional visits during the normal working day. Facilities such as security, portering, and refreshments are also a consideration. Good patient care begins when a patient enters a department and while they are waiting for treatment. Hospital departments should always be a secure and welcoming environment regardless of the time of the appointment. The survey of hours of machine servicing and QA showed a large range in the scheduled downtime between different departments. The way in which this was organised seemed to depend on local factors, such as the availability, expertise and motivation of technical staff and how much QA was deemed necessary. A department’s approach to QA may also be affected by past events, such as adverse incidents and their outcome. A recent RCR/Institute of Physics and Engineering in Medicine/Society and College of Radiographers report on radiotherapy QA recommends that the frequency of linear accelerator QA should not be reduced without a full risk analysis, as in many cases reducing the frequency of checks will lead to increased risks of incidents, and will not be cost-effective [23]. Furthermore, routine extended hours working would require radiotherapy departments to have compatible machines to facilitate direct transfer of patients should a breakdown occur.
221
Servicing and QA carried out during the normal working day accounted for an average of about 161 h/year on each linear accelerator. Moving all maintenance out of hours (were possible) might allow a significant increase in capacity without increasing the length of the working day, but this simply shifts the problem on to another workgroup that also has a limited workforce from which to draw. It has to be remembered that although a linear accelerator could be run for 11.5 h by two radiographer shifts, it is probable that radiotherapy physics would need to use three shifts, as at least an additional hour would be required for support before and/or after the treatment hours. The working day would be longer still if a machine broke down and was to be made ready before the next treatment day. The rhythms of our society are relatively fixed and tend to become more rigid as we get older. Our patient questionnaire showed that more patients were willing to come for treatment very early in the morning than would consider leaving the house for treatment after their evening meal. As many patients travel long distances for treatment this means that most patients prefer to have treatment between 9.00 am and 6.00 pm, thus allowing them to maintain the normal pattern of family life through a 4 or 6 week course of daily treatment. However, two out of five patients would consider appointments outside of the normal working day, showing patient support for a moderate extension to the normal day. An extended day is perhaps at best limited to 8.00 am to 8.00 pm with an anticipated reduction in patient uptake of appointments after 6.00 pm. Consideration for transport to the radiotherapy facility is important. A hospital ambulance or volunteer car was used by 33.9% of patients who responded to our survey. Public transport (including private taxis) was used by 20%. Out of hours hospital transport is an issue for almost all radiotherapy centres in the UK despite being available to other services such as dialysis units. Patients, particularly the elderly, do not wish to travel on public transport very early or very late in the day, especially in the winter. Although public transport is well developed within most city centres, it is not the case in rural areas. However, our initial patient survey focused on city centre departments. In areas where more patients would be expected to drive to their appointments, patient attitudes to out of hours appointments may be significantly different.
Conclusion If extended hours working is to be used successfully it must be fully scoped before implementation. It should be clear how long the extended hours are expected to be in place, how the hours will be organised, which professional groups will be involved and what the expected measurable outcome will be in terms of increased throughput. This will allow for periodic assessment of how effective the extended working hours are in practice. Working through a business case or working paper will provide focus. Sustained use of extended working hours is best achieved by adopting shift patterns that reflect the hours that
222
CLINICAL ONCOLOGY
patients are willing and able to attend. Apart from the costs and strategic difficulties in working more than an 11.5 h working day, our patient survey suggests that there would be little support from patients for a very extended day. Our findings show that two shifts to cover an 11.5 h working day would be the most cost-effective alternative to the normal working day. We have outlined the risks to the continuity of patient care if an attempt is made to work all the machines in a department on this basis; it will then be extremely difficult to transfer patients to another machine in case of breakdown, unless there is a service continuity machine available. For small departments working some machines for longer hours, this is a safe alternative. Acknowledgements. The authors thank all the individuals who participated in the questionnaire surveys and particularly those who facilitated the department visits and administered the patient questionnaire for and on behalf of the project team. The project was funded by a grant from the Department of Health to the Royal College of Radiologists. Author for correspondence: F. Calman, Guy’s and St Thomas’ NHS Foundation Trust, St Thomas’ Hospital, Lambeth Palace Road, London SE1 7EH, UK. Tel: þ44-020-7188-1447; E-mail: frances. [email protected] Received 21 March 2006; received in revised form 6 January 2007; accepted 25 January 2007
References 1 Department of Health. NHS cancer plan. London: Department of Health; 2000. 2 Coles CE, Burgess L, Tan LT. An audit of delays before and during radical radiotherapy for cervical cancer d effect on tumour cure probability. Clin Oncol (R Coll Radiol) 2003;15:47e54. 3 O’Rourke N, Edwards R. Lung cancer treatment waiting times and tumour growth. Clin Oncol (R Coll Radiol) 2000;12:141e144. 4 Joint Council for Clinical Oncology. Reducing delays in cancer treatment: some targets. London: Royal College of Physicians; 1993. 5 Summers E, Williams M. Re-audit of radiotherapy waiting times 2005. London: Royal College of Radiologists, 2006 (http://www. rcr.ac.uk/). 6 National Audit Office. The NHS cancer plan: a progress report. London: Stationary Office; 2005. 7 Board of the Faculty of Clinical Oncology. Equipment, workload and staffing for radiotherapy in the UK, 1997e2002. London: Royal College of Radiologists; 2003.
8 Bentzen SM, Heeren G, Cottier B, et al. Towards evidencebased guidelines for radiotherapy infrastructure and staffing needs in Europe: the ESTRO QUARTS project. Radiother Oncol 2005;75:355e365. 9 Radiotherapy Special Interest Group. Staffing levels and skill mix in UK radiotherapy physics departments. Scope 1997;6: 19e25. 10 Department of Health. The NHS improvement plan: putting people at the heart of public services. London: Department of Health; 2004. 11 cancerimprovement.nhs.uk. Leicester: Cancer Services Collaborative ‘Improvement Partnership’; c2005e06 (http: //www.cancerimprovement.nhs.uk/). 12 Board of the Faculty of Clinical Oncology. Extending the working day for delivery of radiotherapy. London: Royal College of Radiologists; 1997. 13 National Cancer Services Analysis Team. A survey of radiotherapy services in the UK. Clatterbridge: NatCanSAT; 2002. 14 Routsis D, Thomas S, Head J. Are extended working days sustainable in radiotherapy? J Radiother Pract 2006;5:77e85. 15 Delaney GP, Shafiq RJ, Jalaludin BB, Barton MB. Technology enhancements and changes in radiotherapy throughput in New South Wales. Clin Oncol (R Coll Radiol) 2005;17:305e310. 16 nhsemployers.org. London: NHS Confederation; c2005 (http:// www.nhsemployers.org/). 17 College of Radiographers. Radiographic staffing: short term guidance. 2005 benchmark for standard core functions within radiotherapy, 1st edn. London: Society of Radiographers; 2005. 18 Board of the Faculty of Clinical Oncology. Guidelines for the management of unscheduled interruption or prolongation of a radical course of radiotherapy, 2nd edn. London: Royal College of Radiologists; 2002. 19 Dale RG, Hendry JH, Jones B, Robertson AG, Deehan C, Sinclair JA. Practical methods for compensating for missed treatment days in radiotherapy, with particular reference to head and neck schedules. Clin Oncol (R Coll Radiol) 2002;14:382e393. 20 Hendry JH, Bentzen SM, Dale RG, et al. A modelled comparison of the effects of using different ways to compensate for missed treatment days in radiotherapy. Clin Oncol (R Coll Radiol) 1996; 8:297e307. 21 Lievens Y, van den Bogaert W, Kesteloot K. Activity-based costing: a practical model for cost calculation in radiotherapy. Int J Radiat Oncol Biol Phys 2003;57:522e535. 22 Dunscombe P, Roberts G, Walker J. The cost of radiotherapy as a function of facility size and hours of operation. Br J Radiol 1999;72:598e603. 23 McKenzie A, Briggs G, Buchanan R, et al. Balancing costs and benefits of checking in radiotherapy. York: Institute of Physics and Engineering in Medicine; 2006.